Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Summary

Confluent Health is required by law to maintain the privacy of individually identifiable health information about you, to provide this Notice of our legal duties and privacy practices, notify affected individuals following a breach of unsecured protected health information and to abide by the terms of this Notice.

We may use or disclose health information about you for the purpose of your treatment, and also to the extent necessary to obtain payment for treatment and for certain administrative purposes, including evaluation of the quality of care that you receive. We may also use or disclose identifiable health information about you without your authorization in certain other circumstances. For example, subject to certain requirements, for public health purposes, for auditing purposes, for research studies, and for emergencies. We also provide health information when required by law.

Uses or disclosures other than those described in this Notice will be made only with your written authorization. If you do authorize a use or disclosure, you have the right to take back or “revoke” your authorization at any time by submitting a revocation in writing. We are unable to take back any use or disclosure that we have taken an action in reliance on the use or disclosure as previously indicated.

For additional information, or to make a complaint with respect to your privacy rights, you may contact our Compliance Department or to the Department of Health and Human Services Office for Civil Rights, contact information is listed at the end of this Notice.

Protected Health Information

Protected health information (PHI) is your information created or received by a healthcare provider that relates to your past, present or future physical or mental health or condition, to the provision of health care to you, or to payment for your health care.

How We May Use and Disclose Protected Health Information About You

We may use or disclose your protected health information without your consent or authorization for purposes of your treatment, for payment purposes, and for certain administrative and other health care operations.

Treatment:

We will use and disclose your protected health information to provide, coordinate or manage health care provided by us and by other health care providers. For example, information obtained by a Therapist or any other healthcare professional will be used to determine and document the course of treatment that works best for you. We will also provide your physician or subsequent healthcare provider with copies of various reports that should assist them in treating you and to continue care.

Payment:

We may use or disclose your protected health information as needed to obtain payment for health care services we provide. For example, a bill may be sent to you or a claim for payment may be sent to a third-party payer such as an insurance company. The information on or accompanying the bill or claim may include information such as your name, date of birth, social security number and address, as well as your diagnosis and procedures and supplies used.

Health Care Operations:

We may use or disclose your protected health information in order to support our business activities and health care operations. These activities include, but are not limited to, quality assessment audits and improvement activities, communication about products or services, reviewing the competence or qualification of health care professionals, conducting training programs, business planning and development, business management and general administrative activities.

Business Associates. There are some services provided in our organization through business contracts. When these services are contracted, we may disclose your protected health information to our business associate, so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your protected health information.

I acknowledge and understand that this office may contact and survey me via e-mail regarding my satisfaction and outcomes. I understand that an independent vendor(s) may assist with this data collection. I understand that in addition to the aforementioned confidential survey, this office or their designated vendor may also send an automated email to allow me to voluntarily and publically rate and review my provider online through sites like; Google, Yelp, Keet, etc. I acknowledge that my responses, like other online responses, may be published on the respective review site(s) and will be publicly disclosed and accessible to anyone who accesses that site. I understand that reviews are optional, and I will not include any sensitive, personal, identifying or medial information that I do not wish to be publicly disclosed in an online review i.e. name, contact information, social security number, health history, diagnosis, medications, etc. When submitting a survey or review, I agree to fully release, waive and indemnify this office and/or the associated vendor(s) from any and all claims arising from my voluntary disclosure of protected health information to the sites.

Other Uses and Disclosures That Do Not Require Your Authorization

o Required by law. We may use or disclose your protected health information to the extent that use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

o Public health activities. We may disclose medical information about patients for public health activities. Generally, these activities include the following reports:

 To notify people of recalls of products they may be using;

 To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or

 To notify the appropriate government authority if we believe a patient has been the victim of abuse or neglect, as required by law.

o Employer. We may disclose your protected health information to your employer if we are providing health care to you at the request of your employer to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. We will notify you before making such a disclosure by providing you with written notice at the time we provide health care to you.

o Highly confidential information. Certain Federal and state laws may require special privacy protections for certain highly confidential information about you. Highly confidential information may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as State laws that often protect the following types of information: (1) mental health and/or developmental disabilities services; (2) HIV/AIDS; (3) genetic tests; (4) communicable disease(s); (5) Alcohol and drug abuse; (6) child abuse and neglect; (7) domestic or elder abuse; and/or (8) sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, we will require your written authorization.

o Health oversight activities. We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

o Judicial and administrative proceedings. We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized in the order), and if certain conditions are met, in response to a subpoena, discovery request or other lawful process.

o Law enforcement purposes. We may disclose protected health information, so long as applicable legal requirements are met, to law enforcement officials for law enforcement purposes.

o Research. We may disclose your protected health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocol to ensure measures are in place to preserve the privacy of your protected health information.

o Military Activities. We may, if you are a member of the United States or foreign Armed Forces, disclose your protected health information for activities that are deemed necessary by appropriate military command authorities to assure the proper execution of a military mission.

o Special government functions. We may disclose protected health information for certain specialized government functions, such as national security and intelligence, protective services for heads of state.

o Threats to health or safety. Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

o Workers compensation. We may disclose your protected health information as permitted or required to comply with worker’s compensation laws and other similar legally established programs.

o Relating to decedents or for organ or tissue donations. We may disclose protected health information relating to an individual’s death to coroners, medical examiners or funeral directors for their duties as authorized by law, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.

Uses and Disclosures to Which You Have an Opportunity to Object

o Individuals involved in your care or payment for care. If you consent, do not object, or we reasonably infer that there is no objection, we may disclose protected health information about you to a family member, personal representative or other person identified by you who is involved in your health care or payment for your health care. If you are incapacitated or it is an emergency, we will use our professional judgment to determine whether disclosing protected health information is in your best interest under the circumstances. This includes in the event of your death unless you have specifically instructed us otherwise. You also have the right to request a restriction on our disclosure of your protected health information to someone who is involved in your care.

o Disaster relief. We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

o Right to Request Restrictions for Disclosures Related to Self-Payment. You have the right to request the non-disclosure of health information to a health plan for treatment in situations where you have paid in full out-of-pocket for a health care item or service.

o Psychotherapy Notes. Your authorization is required in order for us to disclose psychotherapy notes. Certain situations do not require your authorization for use of psychotherapy notes, these include use by the originator of the psychotherapy notes for treatment; use in training programs in which students, trainees or practitioners in mental health learn to practice and improve their skills; use in order to defend a legal proceeding brought by you; and any other use permitted by law.

o Marketing. Your authorization is required for any use or disclosure of protected health information for marketing except in situations in which the communication is in the form of a face-to face communication or a promotional gift.

o Sale. Your authorization is required for any disclosure of protected health information which is a sale, as defined under applicable law.

Your Rights Regarding Your Protected Health Information

You have the following rights relating to your protected health information. You will need to give written request in order to exercise these rights. Forms for these purposes are available in our office(s), or you may call the office(s) to request the forms be sent to you.

To request restrictions: You have the right to request that we restrict the uses or disclosures of your information for treatment, payment or healthcare operations. You may also request that we limit the information we share about you with a relative or friends.

In most cases we are not required to agree to patient request to restrict except, you have the right to restrict disclosures of information to your commercial health information plan regarding services or products that you have paid for in full, out-of-pocket, we must grant such a request. In all other cases, we are not required to agree to requests. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment and/or safe patient care and we cannot agree to limit uses or disclosures that are required by law.

Request for restriction must be made in writing and include: (i) what information you want to limit, (ii) whether you want to limit use or disclosure or both and (iii) to whom you want the limits to apply. We may terminate our agreement to a restriction by notifying you. Termination of the agreed restriction will only apply to protected health information received after notice was given to you.

To choose how we contact you: You have the right to ask that we send your information at an alternative address or by an alternative means. For example, you can ask that we only contact you by mail or at work.

Request must be made in writing, you do not need to give us a reason for your request. We must agree to your request as long as it is reasonably easy for us to do so. When appropriate, we may condition the provision of a reasonable accommodation upon receiving information relating to how payment arrangements will be made.

To inspect and obtain a copy your protected health information: With a few exceptions (such as psychotherapy notes and records compiled in anticipation of litigation), you have a right to inspect or receive copies of your protected health information that is kept in a “designated record set.” A “designated record set” is a group of records that includes billing records and records used to make decisions about you. If your protected health information is maintained in an electronic format, you are permitted to receive access to information you requested in electronic format or may have the information transmitted electronically to a designated recipient. We will abide by your request in the format you have requested, if it is feasible to do so, if we cannot, we will attempt to provide your information in an alternative format that you agree to. You may be charged a fee for the cost of copying, mailing or other expenses associated with your request.

If we deny your access, you may ask for our decision to be reviewed. We will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied the request. We will comply with the outcome of the review.

To request amendment of your protected health information: If you believe that your information is incorrect or incomplete, you may ask that the information is amended. You have the right to request an amendment for as long as the information is maintained by us.

A request for amendment must be made in writing. Request for an amendment will be denied if it is not in writing or does not include a reason to support the request. In addition we may deny the request if the protected health information is: (i) correct and complete; (ii) not created by us and/or not part of our records; (iii) not permitted to be disclosed; or (iv) not part of a designated record set.

If we approve the amendment, we will make appropriate changes and inform you and others, as needed or required. If we deny your request, we will explain the denial in writing to you and explain any further steps you may wish to take.

To find out what disclosures have been made: You have the right to request an accounting of disclosures. This is a list of disclosures we have made regarding your protected health information. A request for an accounting must be in writing and must state the time period that may not be longer than six years prior to the date on which you request the list and may not include dates before April 14, 2003.

Certain types of disclosures are not included in such an accounting, these include disclosures made for treatment, payment and healthcare operations; incidental to permitted uses/disclosures; your family, or the facility directory, or pursuant to your written authorization; disclosures made for national security purposes, to law enforcement officials or correctional facilities. If specific personal identifying information has been removed before disclosure, we may not be required to include such a disclosure in the list.

The first request within a 12-month period will be provided for free, there may be a charge for more frequent requests. If there will be a charge, we will notify you of the cost in advance.

To receive this notice: You have a right to receive a paper copy of this Notice upon request.

We reserve the right to change our Notice of Privacy Practices and to make the new provisions effective for all protected health information we maintain, including protected health information received in the past as well as protected health information received after the effective date of the new Notice. A current copy of our Notice will be posted in our office(s) and will also be available on our web site, www.goconfluent.com. You may also obtain a copy by writing or calling the office and asking that one be mailed to you or by asking for one the next time you are in our office.

To be notified following a breach of the patient’s unsecured protected health information. In the unlikely event that a patient’s unsecured protected health information has been compromised, Confluent Health will notify the patient of such an incident.

For questions or complaints, please contact:

Compliance Department

Toll free: 888-937-4479

For More Information or to Make a Complaint

If you believe your privacy rights have been violated, you can file a complaint with our Compliance Department toll free at 888-937-4479 or the Department of Health and Human Services Office for Civil Rights at www.hhs.gov or you may email OCR at [email protected]or call the U.S. Department of Health and Human Services, Office for Civil Rights toll-free at: 1-800-368-1019, TDD: 1-800-537-7697.